Sen. Susan Collins touted the Medicaid expansion in Indiana as a possible model for Maine on Monday, although she was quick to point out it’s not her decision to make. State governments decide whether to expand Medicaid, and Maine is among the 19 states that have not done so.

Medicaid expansion is working in states like Indiana, where the Obama administration approved waivers that permit the program to be operated differently than a traditional expansion, Collins said in a phone interview Monday night with the Portland Press Herald.

Sen. Susan Collins says "Maine is a rural state that has a large low-income population ... that could benefit from Medicaid expansion." Associated Press/J. Scott Applewhite

“I think Indiana came up with a good plan,” the Republican said. “It certainly makes sense to allow a different approach to people who otherwise wouldn’t have health coverage. If Maine does decide to expand Medicaid, a good model for Maine to consider would be the Indiana model.”

Gov. Paul LePage has steadfastly opposed Medicaid expansion and has vetoed several bills passed by the Legislature calling for expansion. A referendum in November will give Maine voters a say on whether to expand Medicaid.

The Obama administration approved waivers allowing Indiana and six other states to expand Medicaid to those earning up to 138 percent of the federal poverty level. The states can charge modest premiums and cost-sharing to help pay for the cost of care.

SENATOR FAVORS MODEST PREMIUMS

In Indiana, families earning between 100 percent and 138 percent of the federal poverty level – about $24,000 to $33,000 in household income for a family of four – pay a modest premium, about $25 per month for insurance that includes vision and dental. Those who don’t or can’t pay still receive health insurance through Medicaid, but have a plan with fewer benefits that don’t include vision and dental.

Collins said she likes that paying a small premium and having low-cost co-pays provides incentives so enrollees don’t use the health care system when it’s not needed. If there’s a small cost, people will use the system more wisely, she said.

“Maine is a rural state that has a large low-income population falling through the cracks that could benefit from Medicaid expansion,” Collins said.

Medicaid – a federal program for low-income and disabled people funded with a blend of federal and state tax dollars – has been the subject of much controversy, with Democrats defending the program for improving the lives of many, and some Republicans arguing that it represents an unaffordable expansion of the welfare state.

Medicaid expansion is a cornerstone of the Affordable Care Act’s effort to reduce the uninsured rate, which has dropped from about 18 percent before the ACA went into effect to 11 percent in 2016. But the program faces an uncertain future, and it lies near the heart of the health care debate that has raged since President Trump assumed office in January and proposed substantial cutbacks to Medicaid.

In the middle of the debate is Collins, a moderate Republican who holds a key vote in a closely divided Senate, where a committee of her Republican colleagues is forging a version of the bill that may determine the fate of the ACA. Collins also has said she is considering running for governor after LePage’s term expires in 2018.

Steve Butterfield, a public policy analyst with Augusta-based Consumers for Affordable Health Care, said he’s “encouraged” by Collins’ statements.

“She deserves a lot of credit in this partisan atmosphere for concentrating on policy-focused solutions,” Butterfield said. “She’s trying to find consensus-based solutions.”

Marc Malon, the Maine representative of Organizing for Action, a national progressive public-policy advocacy group, said that while at times it’s been difficult to discern what Collins intends to do with proposals to replace the ACA, supporting Medicaid expansion in Maine seems to be another signal that she will not support bills that would reduce the number of insured.

“I think she does want to do the right thing,” Malon said.

OPPOSITION TO HOUSE-PASSED BILL

Collins said Monday that her goal is for more people to become insured, not fewer, and that’s one of the major reasons why she is against the American Health Care Act, a bill to replace the ACA that was approved by four votes in the Republican-controlled House on May 4.

“It’s a bill I cannot support,” Collins said of the AHCA. “It’s not acceptable to me to have 23 million people lose coverage over the next decade.”

Collins said she also objects to how the AHCA would be much more expensive for older, rural people in the 50-64 age group, with premiums expected to rise by as much as 800 percent, according to the Congressional Budget Office analysis of the bill.

Collins has partnered with Sen. Bill Cassidy, R-Lousiana, on a proposal to replace the ACA that leaves a lot of the law’s consumer protections in place and aims to expand the number of insured. A separate group of 13 Republican senators supported by Majority Leader Mitch McConnell, R-Kentucky, is working on a bill that would likely be a more conservative approach.

In Maine, Medicaid enrollment has swung wildly depending on the governor and Legislature, and the economy. Currently, about 265,000 people have Medicaid in Maine, down from about 350,000 before LePage took office in 2011.

LePage has tightened eligibility requirements for Medicaid and vetoed Medicaid expansion several times. The referendum on the November ballot to expand Medicaid would, if approved, not be subject to the governor’s veto and would insure an estimated 80,000 people, according to Maine Equal Justice Partners, a progressive advocacy group.

Adrienne Bennett, spokeswoman for the governor, declined to comment on Collins’ position Monday.

The American Health Care Act also would end Medicaid expansion. It is currently before the closely divided Senate, where Collins could play a key role. Only three Republicans would need to vote “no” to scuttle attempts to replace the ACA.

Medicaid expansion has divided Republicans, with some like Collins praising aspects of expansion, while others criticize it.

Among the 31 states that have expanded Medicaid, several have Republican governors, including Ohio, Arizona and Indiana.

The Obama administration approved modified versions of Medicaid expansion for seven states – Arizona, Arkansas, Indiana, Iowa, Michigan, Montana and New Hampshire – in large part to satisfy demands by Republicans to have some of the costs borne by low-income enrollees. Medicaid traditionally has not required its enrollees to pay premiums or co-pays.

Although states have leeway on what populations to cover, most provided Medicaid coverage up to the poverty level, while the expansion paid for the group between 100 percent and 138 percent of the poverty level. Under the ACA, the federal government would pay for 90 percent of the cost of the expansion.

POSITIONING FOR GOVERNOR RUN?

The LePage administration has argued that Medicaid expansion is too expensive and would strain the state budget, a claim disputed by Democrats. The Legislature’s nonpartisan Office of Fiscal and Program Review estimated the state would spend $93 million in state tax dollars on expansion through 2019, but receive nearly $1.2 billion in federal funds.

Kenneth Palmer, emeritus professor of political science at the University of Maine, said Collins may be positioning herself for the 2018 gubernatorial election by taking a popular position that appeals to Democrats, independents and moderate Republicans.

Palmer said Medicaid expansion appeals to many Maine general election voters, and he doesn’t see a right-wing challenger to Collins emerging in a Republican primary should she choose to run.

“If she’s thinking about running, this is a very reasonable move,” he said.

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